Journal of Parenteral and Enteral Nutrition recent issues

A.S.P.E.N. Clinical Guidelines: Nutrition Support of Children With Human Immunodeficiency Virus Infection

Thu, 05 Nov 2009 10:07:44 PST

Butyrate Increases GLUT2 mRNA Abundance by Initiating Transcription in Caco2-BBe Cells

Mangian, H. F., Tappenden, K. A. — Thu, 05 Nov 2009 10:07:44 PST

Background: Glucose transporter 2 (GLUT2) is a high-capacity, facilitative intestinal monosaccharide transporter, known to be upregulated by short-chain fatty acids (SCFAs) derived from the intestinal microbiota during fermentation. Understanding the mechanisms regulating intestinal function is important to optimize therapies for patients with intestinal failure and ultimately reduce their dependence on parenteral nutrition. Objective: The objective was to examine the mechanism regulating the underlying response of GLUT2 to the SCFA butyrate. Methods: GLUT2 messenger RNA (mRNA) abundance was measured in differentiated Caco2-BBe monolayers treated for 0.5-24 hours with 0-20 mM butyrate using quantitative reverse transcription–polymerase chain reaction. Activation of the human GLUT2 promoter was measured using luciferase reporting in transiently transfected Caco2-BBe monolayers. Results: GLUT2 mRNA abundance was higher (P < .0001) with 1-4 hours of exposure to 2.5, 7.5, and 10 mM butyrate. Butyrate induced (P < .0001) promoter activity in a dose-dependent fashion. Analysis of the GLUT2 promoter indicated that regions –282/+522, –216/+522, and –145/+522 had a heightened (P < .05) response to butyrate compared with 1135/+522 and 564/+522. Conclusions: Butyrate upregulates GLUT2 mRNA abundance in Caco2-BBe monolayers by activating specific regions within the human GLUT2 promoter. These results identify a cellular mechanism wherein butyrate upregulates intestinal absorption that may be relevant to patients with reduced function. Additional work is necessary to understand cellular targets of butyrate therapy and define clinically appropriate means of providing such strategies, such as consuming prebiotics and probiotics.

Enteral Refeeding Rapidly Restores PN-Induced Reduction of Hepatic Mononuclear Cell Number Through Recovery of Small Intestine and Portal Vein Blood Flows

Thu, 05 Nov 2009 10:07:44 PST

Background: Absence of enteral nutrition (EN) reduces hepatic mononuclear cell (MNC) numbers and impairs their functions. However, enteral refeeding (ER) for as little as 12 hours following parenteral nutrition (PN) rapidly restores hepatic MNC numbers. We hypothesized that changes in small intestine and portal vein blood flows related to feeding route might be responsible for this phenomenon. Methods: In experiment 1, mice (n = 19) were randomized to Chow (n = 5), PN (n = 7) or ER (n = 7) groups. The Chow group was given chow ad libitum with intravenous (IV) saline for 5 days. The PN group was fed parenterally for 5 days, while the ER group was re-fed with chow for 12 hours following 5 days of PN. Then, small intestine and portal vein blood flows were monitored and hepatic MNCs were isolated and counted. In experiment 2, the effects of intravenous administration of prostaglandin E₁ (PGE₁) on hepatic MNC numbers were examined in fasted mice for 12 hours. Mice (n = 28) were randomized to Control (n = 8), PG0 (n = 10), or PG1 (n = 10) groups. The Control group was fed chow ad libitum with IV saline, while the PG0 and PG1 groups were fasted for 12 hours with infusions, respectively, of saline and PGE₁ at 1 µg/kg/minute. Blood flows and hepatic MNC numbers were examined. Results: Experiment 1: ER restored PN-induced reductions in small intestine and portal vein blood flows and hepatic MNC number to the levels in the Chow group. Small intestine and portal vein blood flows correlated positively with hepatic MNC number. Experiment 2: Fasting decreased small intestine and portal vein blood flows and hepatic MNC number. However, PGE₁ restored portal vein blood flow to the level of the Control group, and moderately increased hepatic MNC number. There was a positive correlation between portal blood flow and hepatic MNC number. Conclusions: Reduced small intestine and portal vein blood flows may contribute to impaired hepatic immunity in the absence of EN. ER quickly restores hepatic MNC number through recovery of blood flow in both the small intestine and the portal vein.

Colonic GLP-2 is not Sufficient to Promote Jejunal Adaptation in a PN-Dependent Rat Model of Human Short Bowel Syndrome

Thu, 05 Nov 2009 10:07:44 PST

Background: Bowel resection may lead to short bowel syndrome (SBS), which often requires parenteral nutrition (PN) due to inadequate intestinal adaptation. The objective of this study was to determine the time course of adaptation and proglucagon system responses after bowel resection in a PN-dependent rat model of SBS. Methods: Rats underwent jugular catheter placement and a 60% jejunoileal resection + cecectomy with jejunoileal anastomosis or transection control surgery. Rats were maintained exclusively with PN and killed at 4 hours to 12 days. A nonsurgical group served as baseline. Bowel growth and digestive capacity were assessed by mucosal mass, protein, DNA, histology, and sucrase activity. Plasma insulin-like growth factor I (IGF-I) and bioactive glucagon-like peptide 2 (GLP-2) were measured by radioimmunoassay. Results: Jejunum cellularity changed significantly over time with resection but not transection, peaking at days 3-4 and declining by day 12. Jejunum sucrase-specific activity decreased significantly with time after resection and transection. Colon crypt depth increased over time with resection but not transection, peaking at days 7-12. Plasma bioactive GLP-2 and colon proglucagon levels peaked from days 4-7 after resection and then approached baseline. Plasma IGF-I increased with resection through day 12. Jejunum and colon GLP-2 receptor RNAs peaked by day 1 and then declined below baseline. Conclusions: After bowel resection resulting in SBS in the rat, peak proglucagon, plasma GLP-2, and GLP-2 receptor levels are insufficient to promote jejunal adaptation. The colon adapts with resection, expresses proglucagon, and should be preserved when possible in massive intestinal resection.

Measurement of Resting Energy Expenditure in Healthy Children

Mellecker, R. R., McManus, A. M. — Thu, 05 Nov 2009 10:07:44 PST

Background: The role that the components of energy expenditure play in the etiology of childhood obesity has highlighted the need for greater accuracy and standardized protocols for the measurement of resting energy expenditure (REE). However, protocols used to assess REE in children are varied, and consensus on a suitable method for measuring REE in children has not been reached. This study was undertaken to determine the effect of measurement time and measurement device (mask or mouthpiece) on REE in healthy children. Design: Following a 12-hour fast and abstinence from exercise, 23 children (age, 7–12 years) completed two 35-minute protocols: one with a face mask and the other with a mouthpiece/noseclip. Energy expenditure was measured continuously via indirect calorimetry, while device acceptability was assessed using a 6-point comfort rating scale. Results: Repeated measures ANOVA indicated that there was no significant difference in REE when measured after 10, 15, 20, or 25 minutes of rest compared to 30 minutes for either the mask or mouthpiece/noseclip (REE range, 1371–1460 kcal/d). Examination of the percentage coefficient of varia tion (CV) in energy expenditure for each time period by device showed that the least variation existed after 20 minutes of measurement using the mask (CV 6%). Paired t test analysis indicated significantly less discomfort when wearing the mask compared to the mouthpiece/noseclip. Conclusion: It would appear that a 20-minute protocol using a mask may increase compliance and prove to be a more practical protocol for measuring REE in children.

Disparate Response to Metoclopramide Therapy for Gastric Feeding Intolerance in Trauma Patients With and Without Traumatic Brain Injury

Thu, 05 Nov 2009 10:07:44 PST

Patients with traumatic brain injury (TBI) have delayed gastric emptying and often require prokinetic drug therapy to improve enteral feeding tolerance. The authors hypothesized that metoclopramide was less efficacious for improving gastric feeding tolerance for trauma patients with TBI compared to trauma patients without TBI. A retrospective analysis was conducted of patients admitted to the trauma or neurosurgical intensive care unit who received gastric feeding from January 2006 to April 2008. Gastric feeding intolerance was defined by a gastric residual volume >200 mL or emesis with abdominal distension or discomfort. Patients with gastric feeding intolerance were given metoclopramide 10 mg intravenously every 6 hours, followed by a dose escalation to 20 mg, and then combination therapy with metoclopramide and erythromycin 250 mg intravenously every 6 hours if intolerance persisted. In total, 882 trauma patients (49% with TBI) were evaluated. TBI patients had a higher incidence of gastric feeding intolerance than those without TBI (18.6% vs 10.4%, P ≤ .001). Efficacy rates for metoclopramide 10 mg, metoclopramide 20 mg, and metoclopramide-erythromycin were 55%, 62%, and 79%, respectively (P ≤ .03). Metoclopramide failure occurred in 54% of patients with TBI compared to 35% of patients without TBI, respectively (P ≤ .02), due to a greater prevalence of tachyphylaxis. Single-drug therapy with metoclopramide was less effective for TBI trauma patients compared to trauma patients without TBI. Combination therapy with erythromycin as first-line therapy for TBI trauma patients with gastric feeding intolerance is indicated if there are no contraindications or significant drug interactions.

Riboflavin Status in Acutely Ill Patients and Response to Dietary Supplements

Gariballa, S., Forster, S., Powers, H. — Thu, 05 Nov 2009 10:07:44 PST

Background: Although a number of studies have reported riboflavin deficiency in free-living older people, no data are available on riboflavin intake and status in older people during acute illness. Methods: To determine the riboflavin response to dietary supplements during acute illness, 297 hospitalized, acutely ill older patients are randomly assigned to receive a daily oral nutritional supplement containing 1.3 mg of riboflavin or a placebo for 6 weeks. Outcome measures are riboflavin intake and riboflavin biochemical status at baseline, 6 weeks, and 6 months using the erythrocyte glutathione reductase activation coefficient (EGRAC), a measure of riboflavin tissue saturation. EGRAC values are inversely proportional to riboflavin status. Results: Fifty-six percent of patients (167/297) have suboptimal riboflavin status (EGRAC > 1.30). No significant correlation is found between EGRAC and either total energy or riboflavin intakes. Significant correlations are found between total energy intake and riboflavin intakes both in hospital and at home (r = 0.67, P < .0001 and r = 0.57, P < .0001, respectively). Smokers and patients with chronic obstructive pulmonary disease (COPD) have lower riboflavin status (high EGRAC values) compared with nonsmokers and those without COPD. Riboflavin status improves significantly in the supplement group at 6 weeks compared with the placebo group, but status declines between 6 weeks and 6 months, after patients stop taking the supplements. Conclusions: A high proportion of acutely ill patients have suboptimal riboflavin status. Supplementation with a physiological amount of riboflavin in a mixed-nutrient supplement significantly improves riboflavin status, but the effect is transient and status deteriorates again after patients stop taking the supplements.

Intestinal Redox Status of Major Intracellular Thiols in a Rat Model of Chronic Alcohol Consumption

Thu, 05 Nov 2009 10:07:44 PST

Background: Alcohol consumption is associated with oxidative stress in multiple tissues in vivo, yet the effect of chronic alcohol intake on intestinal redox state has received little attention. In this study, we investigated the redox status of 2 major intracellular redox regulating couples: glutathione (GSH)/glutathione disulfide (GSSG) and cysteine (Cys)/cystine (CySS) in a rat model of chronic alcohol ingestion. Methods: Sprague-Dawley rats were fed the liquid Lieber-DeCarli diet consisting of 36% ethanol of total calories for 6 weeks. Control rats were pair-fed with an isocaloric, ethanol-free liquid diet. Defined mucosal samples from the jejunum, ileum, and colon were obtained and analyzed by high-performance liquid chromatography (HPLC) for GSH and Cys pool redox status. Mucosal free malondialdehyde (MDA) was measured as an indicator of lipid peroxidation. Results: In the ethanol-fed rats, Cys and mixed disulfide (GSH-Cys) were significantly decreased in all 3 segments of intestinal mucosa. Free MDA was increased in jejunal but not in ileal or colonic mucosa. Chronic ethanol ingestion significantly increased mucosal GSH concentration in association with a more reducing GSH/GSSG redox potential in the jejunum, but these indices were unchanged in the ileum. In the colon, chronic ethanol ingestion increased oxidant stress as suggested by decreased GSH and oxidized GSH/GSSG redox potential. Conclusions: Chronic alcohol intake differentially alters the mucosal redox status in proximal to distal intestinal segments in rats. Such changes may reflect different adaptability of these intestinal segments to the oxidative stress challenge induced by chronic ethanol ingestion.

Clinical Application of Magnetic Resonance Spectroscopy of the Liver in Patients Receiving Long-Term Parenteral Nutrition

Woodward, J. M., Priest, A. N., Hollingsworth, K. G., Lomas, D. J. — Thu, 05 Nov 2009 10:07:44 PST

Background: Intestinal failure–associated liver disease (IFALD) may have progressed to an advanced stage by the time it becomes evident via laboratory or physical signs. A safe, noninvasive technique for assessing the liver could significantly aid in monitoring the effects of therapeutic intervention, improve the timing of liver and small intestinal transplantation, and increase our understanding of the causes of IFALD. Methods: Six female patients fed intravenously for >1 year and 6 controls matched for body mass index (BMI) underwent liver magnetic resonance scanning with acquisition of ¹H and ³¹P resonance spectra. Areas under the curve for lipid (the sum of CH, CH₂, and CH₃), water, and choline peaks were calculated and expressed semi-quantitatively as ratios of lipid:water and choline:lipid. Phosphomonoester (PME) and phosphodiester (PDE) peak areas were similarly expressed as a ratio. Controls and cases were compared using Mann-Whitney U test; least squares regression analysis was used to compare the effect of measured variables on the lipid:water peak area ratio. Results: Patients and controls were well matched for BMI. Parenteral feeding was associated with a highly significant increase in lipid:water peak ratio (P < .005). Choline:lipid (P < .05) and choline:water (not significant) ratios were reduced in patients compared with controls. The increase in lipid:water ratios in patients was independent of BMI and choline:water ratios. A ratio of PME:PDE of >0.3 (and >3 SD from the control mean) predicted the 2 patients at most risk of advanced liver disease. Conclusions: This pilot study confirms the potential of magnetic resonance spectroscopic techniques in evaluating IFALD and could contribute significantly to our understanding and management of this condition.

Intravascular Embolization of Venous Catheter--Causes, Clinical Signs, and Management: A Systematic Review

Thu, 05 Nov 2009 10:07:44 PST

Background: Intravascular embolization of device fragments is a rare but potentially serious complication. Method: A systematic search of the PubMed and MEDLINE databases for all articles pertaining to central catheter related embolization published in English between 1985 and 2007 was made. Results: A total of 215 cases of intravenous catheter embolization were identified. There were 143 totally implanted venous devices (TIVD) or port catheters and 72 percutaneous venous catheters (PVC). Sites of catheter fragments following embolization were the superior vena cava or peripheral veins (15.4%), the right atrium (27.6%), right ventricle (22%), and pulmonary arteries (35%). Clinical signs of catheter embolization included catheter malfunction (56.3%), arrhythmia (13%), pulmonary symptoms (4.7%), and septic syndromes (1.8%), but 24.2% of cases were asymptomatic. The causes of intravascular catheter embolization were pinch-off syndrome (40.9%), catheter injury during explantation (17.7%), catheter disconnection (10.7%), and catheter rupture (11.6%). In 19.1% of cases, the cause of catheter embolization could not be identified. Most embolized catheter fragments (93.5%) were removed percutaneously. In 4.2% of cases, fragments were retained in the vascular bed; in 2.3%, embolized fragments were removed surgically via thoracotomy. Conclusion: Intravascular catheter embolization can go undiagnosed for prolonged periods. Patients might be asymptomatic or may develop severe systemic clinical signs. The mortality rate is 1.8%. There were no significant differences in clinical features of embolization between TIVD and PVC groups.

Laparoscopic Surgery Improves Blood Glucose Homeostasis and Insulin Resistance Following Distal Gastrectomy for Cancer

Kanno, H., Kiyama, T., Fujita, I., Tani, A., Kato, S., Tajiri, T., Barbul, A. — Thu, 05 Nov 2009 10:07:44 PST

Background: Prevention of blood glucose elevation and insulin resistance could be more pronounced in patients undergoing laparoscopic rather than open gastrectomy. Methods: Fifty-seven patients underwent distal gastrectomy by either laparoscopy (n = 36) or an open approach (n = 21). Blood glucose, serum insulin, and the daily insulin secretion rate (urinary C-peptide) were measured. Insulin resistance was evaluated using an adapted homeostasis model assessment of insulin resistance (HOMA-R). Results: Blood glucose levels were lower in the laparoscopy group than in the open group on the operative day and on postoperative days (POD) 1 and 3 (P < .001, P = .001, and P = .024, respectively). Serum insulin levels were lower in the laparoscopy group than in the open group on POD 1 and 3 (P = .045 and P = .027, respectively). HOMA-R was lower in the laparoscopy group than in the open group on POD 1 and 3 (P = .024 and P = .009, respectively). Daily insulin secretion rates were lower in the laparoscopy group than in the open group on POD 1 (P = .023). Conclusions: Laparoscopic surgery prevents blood glucose elevation and improves insulin resistance compared with open surgery.

Neonatal Parenteral Nutrition Hypersensitivity: A Case Report Implicating Bisulfite Sensitivity in a Newborn Infant

Huston, R. K., Baxter, L. M., Larrabee, P. B. — Thu, 05 Nov 2009 10:07:44 PST

This report describes a case of parenteral nutrition hypersensitivity in a 37 weeks' gestation infant with congenital diaphragmatic hernia complicated by bowel necrosis and functional short bowel syndrome. The patient developed a rash with subsequent urticaria beginning on the 50th day of life. The reactions were confirmed with a positive rechallenge. After the amino acid solution was replaced with a non–bisulfite-containing product, the infant was able to continue to receive nutrition support through parenteral nutrition without recurrence of symptoms. It is speculated that the bisulfite additive in the amino acid solution may have interacted with the lipid emulsion to sensitize the patient.

Low Availability of Aluminum in Formulations for Parenteral Nutrition Containing Silicate

Thu, 05 Nov 2009 10:07:44 PST

Background: Silicate (Si) and aluminum (Al) may be concomitant impurities in solutions for parenteral nutrition (PN). Silicate can bind to Al to form stable hydroxyaluminosilicates (HAS), thus reducing Al availability. This possibility is investigated by heating solutions containing constituents of PN in glass containers to promote the release of Si and Al. Methods: The total amount of Si and Al in solution is measured by atomic absorption spectrometry, and the Al not bound to Si is evaluated by reaction with morin. Results: When the Si:Al molar ratio is >5, no free Al is found in solution. For ratios <5, it is found that the lower the ratio, the higher the free Al fraction. However, in solutions of some amino acids, even with a low Si:Al ratio (<2), the amount of free Al is lower than that found in other solutions. The same tendency is observed among commercial formulations. Although in salt solutions the free fraction of Al reaches almost 100% when the Si concentration is low, in amino acid formulations the free fraction of Al does not surpass 50%. Moreover, even for Si:Al ratios >5, there is a "residual" fraction of free Al in amino acid formulations. Conclusions: The concomitant presence of Al and Si in solutions for PN reduces the amount of Al available attributable to the formation of HAS. In amino acid formulations this effect may be slightly reduced given the affinity of certain amino acids for Al. Therefore, amino acids may behave in the same fashion as silicate.

Enteral Nutrition and Cardiovascular Failure: From Myths to Clinical Practice

Berger, M. M., Chiolero, R. L. — Thu, 05 Nov 2009 10:07:44 PST

Cardiovascular failure and low flow states may arise in very different conditions from both cardiac and noncardiac causes. Systemic hemodynamic failure inevitably alters splanchnic blood flow but in an unpredictable way. Prolonged low splanchnic blood flow causes intestinal ischemia, increased mucosal permeability, endotoxemia, and distant organ failure. Mortality associated with intestinal ischemia is high. Why would enteral nutrition (EN) be desirable in these complex patients when parenteral nutrition could easily cover energy and substrate requirements? Metabolic, immune, and practical reasons justify the use of EN. In addition, continuous enteral feeding minimizes systemic and myocardial oxygen consumption in patients with congestive heart failure. Further, early feeding in critically ill mechanically ventilated patients has been shown to reduce mortality, particularly in the sickest patients. In a series of cardiac surgery patients with compromised hemodynamics, absorption has been maintained, and 1000-1200 kcal/d could be delivered by enteral feeding. Therefore, early EN in stabilized patients should be attempted, and can be carried out safely under close clinical monitoring, looking for signs of incipient intestinal ischemia. Energy delivery and balance should be monitored, and combined feeding considered when enteral feeds cannot be advanced to target within 4-6 days.

Malnutrition Syndromes: A Conundrum vs Continuum

Jensen, G. L., Bistrian, B., Roubenoff, R., Heimburger, D. C. — Thu, 05 Nov 2009 10:07:44 PST

This provocative commentary critically examines historic definitions for adult malnutrition syndromes as they apply to developed countries with modern healthcare. To stimulate further discussion, the authors propose an updated approach that incorporates current understanding of the systemic inflammatory response to help guide assessment, diagnosis, and treatment. An appreciation of a continuum of inflammatory response in relation to malnutrition syndromes is described. This discussion serves to highlight a research agenda to address deficiencies in diagnostics, biomarkers, and therapeutics of inflammation in relation to malnutrition.

How Immunocompromised Are Short Bowel Patients Receiving Home Parenteral Nutrition? Apropos a Case of Disseminated Fusarium Oxysporum Sepsis

Muller, C., Schumacher, U., Gregor, M., Lamprecht, G. — Thu, 05 Nov 2009 10:07:44 PST

Background: Catheter-related sepsis is the most frequent complication in patients receiving home parenteral nutrition (HPN) for short bowel syndrome (SBS). A low-grade systemic inflammatory state and an altered mucosal immune response, as well as diminished intestinal barrier function have been characterized in these patients. The possibility of systemic immunocompromise has only recently been suggested. Case Description: A 45-year-old female with traumatic SBS was admitted for possible catheter-related sepsis. She was asplenic and had insulin-dependent diabetes mellitus as a result of a pancreatic resection. A large skin ulceration was present on her left calf, which appeared unusual for a disseminated bacterial infection. Chest x-ray and computed tomography scan revealed multiple subpleural pulmonary infiltrates consistent with bacterial or fungal dissemination. Blood cultures from the port system and from the peripheral blood grew Staphylococcus haemolyticus and Fusarium oxysporum. The port system was removed, and flucloxacillin and voriconazole were given for 33 and 35 days, respectively. Clinical signs of disseminated sepsis resolved slowly. Bone marrow biopsy ruled out primary hematologic disease. Conclusions: (1) Catheter-related sepsis in patients on HPN is usually caused by Gram-positive or Gram-negative bacteria or by Candida species. Identification of molds in blood cultures strongly suggests Fusarium species, which should be treated appropriately with voriconazole or amphotericin B. (2) HPN and SBS aggravated by asplenism and diabetes mellitus can cause severe immunocompromise. (3) Fusaria have a strong tendency to persist or reappear after bone marrow transplantation, which is therefore relatively contraindicated in these patients.

Percutaneous Gastrojejunostomy Placement in a Heart Failure Patient With Biventricular Assist Devices

Page, S., Cecere, R., Valenti, D. — Thu, 05 Nov 2009 10:07:44 PST

Heart failure patients who require a ventricular assist device often present a nutrition challenge. A 39-year-old woman suffering from an acute ST elevated myocardial infarction and severe cardiogenic shock underwent implant of left and right ventricular assist devices (BiVAD). Neurologic deficits prevented her from safely resuming oral intake, and long-term feeding access was required. The decision was made to insert a percutaneous gastrojejunostomy under fluoroscopic guidance. Patients implanted with ventricular assist devices may require enteral nutrition support. Placement of feeding access other than through the nasoenteric route can be rendered more challenging because of anatomical constraints related to BiVAD positioning; however, whenever enteral nutrition support is required for extended periods, percutaneous or ostomy access offers easier delivery of nutrition. Although technically difficult, successful placement of the enteral feeding tube allowed for continuous 24-hour feeds to optimize nutrition intake. This is the first time that a percutaneous enteral feeding access was obtained for a ventricular assist device patient at the authors' institution, and it has proven valuable in providing long-term nutrition in a safe and efficient manner.

Unanswered Questions of "ProCon"etic Therapy

MacLaren, R. — Thu, 05 Nov 2009 10:07:44 PST

Imaging Biochemistry Noninvasively: Magnetic Resonance Spectroscopy in Liver Disease

Serkova, N. J. — Thu, 05 Nov 2009 10:07:44 PST

Comment on: Measurement of Resting Energy Expenditure in Healthy Children

Bogucki, E. L. — Thu, 05 Nov 2009 10:07:44 PST

Background: The role that the components of energy expenditure play in the etiology of childhood obesity has highlighted the need for greater accuracy and standardized protocols for the measurement of resting energy expenditure (REE). However, protocols used to assess REE in children are varied, and consensus on a suitable method for measuring REE in children has not been reached. This study was undertaken to determine the effect of measurement time and measurement device (mask or mouthpiece) on REE in healthy children. Design: Following a 12-hour fast and abstinence from exercise, 23 children (age, 7–12 years) completed two 35-minute protocols: one with a face mask and the other with a mouthpiece/noseclip. Energy expenditure was measured continuously via indirect calorimetry, while device acceptability was assessed using a 6-point comfort rating scale. Results: Repeated measures ANOVA indicated that there was no significant difference in REE when measured after 10, 15, 20, or 25 minutes of rest compared to 30 minutes for either the mask or mouthpiece/noseclip (REE range, 1371–1460 kcal/d). Examination of the percentage coefficient of variation (CV) in energy expenditure for each time period by device showed that the least variation existed after 20 minutes of measurement using the mask (CV 6%). Paired t test analysis indicated significantly less discomfort when wearing the mask compared to the mouthpiece/noseclip. Conclusion: It would appear that a 20-minute protocol using a mask may increase compliance and prove to be a more practical protocol for measuring REE in children.(JPEN J Parenter Enteral Nutr. 2009;33:640-645)

Prebiotics and Enteral Feeding-Associated Diarrhea

Hegazi, R., Strausbaugh, K., Merritt, R. — Thu, 05 Nov 2009 10:07:44 PST

Author Response

Barrett, J. S, Shepherd, S. J., Gibson, P. R. — Thu, 05 Nov 2009 10:07:44 PST

Letter to the Editor

Williams-Dolan, J. M., Boullata, J. I. — Thu, 05 Nov 2009 10:07:44 PST

Can We Make A.S.P.E.N.'s Clinical Nutrition Week the Pre-eminent International Nutrition Meeting?

McClave, S. A. — Thu, 27 Aug 2009 13:41:07 PDT

A.S.P.E.N. Clinical Guidelines: Nutrition Support Therapy During Adult Anticancer Treatment and in Hematopoietic Cell Transplantation

Thu, 27 Aug 2009 13:41:07 PDT

Evolution of Lipid Profile, Liver Function, and Pattern of Plasma Fatty Acids According to the Type of Lipid Emulsion Administered in Parenteral Nutrition in the Early Postoperative Period After Digestive Surgery

Thu, 27 Aug 2009 13:41:07 PDT

Background: The metabolic effects of intravenous lipid emulsions (ILEs) used in parenteral nutrition (PN) depend on their fatty acid composition. Methods: Subjects in this prospective and randomized double-blind study were 28 adult patients post digestive surgery. PN was started after surgery and lasts for 5 days. Randomly, patients receive 1 of 4 different ILEs: medium-chain triglycerides/long-chain triglycerides (soybean oil; MCT/LCT), olive/soybean oil (oleic), long-chain triglycerides (soybean oil; LCT), and structured lipid. On days 0 and 6, serum liver function tests were analyzed for cholesterol, triglycerides, lipoproteins, and serum fatty acids. Results: No differences were found in the 4 groups according to their gender, age, body mass index, diagnosis, baseline white blood cell, C-reactive protein, glucose levels, and other study parameters. Differential significant changes were not observed in any of the hepatic function parameters or plasmatic lipid levels between the groups. A significant decrease was observed in cis monounsaturated fatty acids (MUFAs) and a significant increase in -6 polyunsaturated fatty acids (PUFAs) and -3 PUFA values in LCT and structured groups compared with MCT/LCT and oleic groups, and a tendency for a decrease in trans fatty acids in the oleic and structured groups was found. Conclusions: All ILEs administered were safe and well tolerated. The changes in serum fatty acids reflected the pattern of fatty acids administered with different ILEs. The group receiving the olive oil emulsion achieved a fatty acid composition of serum lipids that could offer major therapeutic or biological advantages.

Inhibition of Gastroesophageal Reflux by Semi-solid Nutrients in Patients With Percutaneous Endoscopic Gastrostomy

Thu, 27 Aug 2009 13:41:07 PDT

Background: Aspiration is one of the major complications after percutaneous endoscopic gastrostomy (PEG). The administration of semi-solid nutrients by means of gastrostomy tube has recently been reported to be effective in preventing aspiration pneumonia. The effects of semi-solid nutrients on gastroesophageal reflux, intragastric distribution, and gastric emptying were evaluated. Methods: Semi-solid nutrients were prepared by liquid nutrients mixed with agar at the concentration of 0.5%. The distribution of the administered radiolabeled liquid and semi-solid nutrients was monitored by a scintillation camera for 15 post-PEG patients. The percentage of esophageal reflux, the distribution of the proximal and distal stomach, and the gastric emptying time were evaluated. Results: The percentage of gastroesophageal reflux was significantly decreased in semi-solid nutrients (0.82 ± 1.27%) compared with liquid nutrients (3.75 ± 4.25%), whereas the gastric emptying time was not different. The distribution of semi-solid nutrients was not different from liquid nutrients in the early phase, whereas higher retention of liquid nutrients in the proximal stomach was observed in the late phase. Conclusions: Gastroesophageal reflux was significantly inhibited by semi-solid nutrients. One of the mechanisms of the inhibition is considered to be an improvement in the transition from the proximal to distal stomach in semi-solid nutrients.

Intestinal Dipeptide Absorption Is Preserved During Thermal Injury and Cytokine Treatment

Foster, D. R., Gonzales, J. P., Amidon, G. L., Welage, L. S. — Thu, 27 Aug 2009 13:41:07 PDT

Background: Intestinal barrier function is impaired during thermal injury; however, the effects of thermal injury on the absorption of dietary peptides are not well characterized. The purpose of this study was to determine the impact of thermal injury on dipeptide absorption in rats and to describe the influence of inflammatory cytokines on the expression of the oligopeptide transporter PEPT1 and dipeptide permeability in cultured intestinal cells (Caco-2 cells). Methods: Sprague Dawley rats were assigned to 30% body surface area burn (n = 7) or sham (n = 8) groups. Twenty-four hours following burn/sham, the proximal jejunum was cannulated. The jejunal segment was perfused with buffer containing the dipeptide glycylsarcosine (Gly-Sar), and intestinal permeability (P_eff) was calculated. For in vitro experiments, Caco-2 cells were grown on permeable supports and treated with tumor necrosis factor (TNF)-, interleukin (IL)-6, and IL-10 (10 ng/mL) alone and in combination for 48 hours. The effective apical-to-basolateral permeabilities (P_eff) of Gly-Sar were measured, and PEPT1 expression was determined using reverse transcription-polymerase chain reaction. Results: Gly-Sar P_eff was similar in burn and sham rats (6.67 ± 2.27 x 10^-5 vs 7.58 ± 2.20 x 10^-5 cm/s, respectively, P = .45). In Caco-2 cells, cytokine treatment did not alter PEPT1 expression (P = .954) or the P_eff of Gly-Sar (P = .806). Conclusions: Intestinal absorption of the dipeptide Gly-Sar is preserved 24 hours following thermal injury in rats. Likewise, PEPT1 expression and peptide absorption are preserved following treatment with TNF-, IL-6, and IL-10 in Caco-2 monolayers. These findings imply that intestinal dipeptide absorption may be preserved during burn injury. This may lead to new strategies to optimize enteral protein delivery in burn patients.

Feeding Jejunostomy for the Treatment of Severe Hyperemesis Gravidarum: A Case Series

Saha, S., Loranger, D., Pricolo, V., Degli-Esposti, S. — Thu, 27 Aug 2009 13:41:07 PDT

Background: Hyperemesis gravidarum is severe nausea and vomiting during pregnancy leading to dehydration, nutrition deficiency, and fetal morbidity and mortality. Treatment must maintain fluid and electrolyte balance and caloric intake. Parenteral nutrition is often attempted; however, complication rates are high. Nutrition via nasoenteric and percutaneous endoscopic gastrostomy tubes is limited by poor patient tolerance, tube dislodgement, and altered anatomy in pregnancy. Methods: Women with hyperemesis gravidarum who failed standard therapy were offered jejunostomy. All patients underwent surgical jejunostomy in the second trimester. Isotonic tube feeds were administered to a goal caloric factor calculated by the Harris-Benedict equation with a correction added for pregnancy. Patients were monitored until delivery. Results: Five women underwent jejunostomy placement at our institution between 1998 and 2005. One patient underwent jejunostomy placement twice for consecutive pregnancies. The mean body weight loss from prepregnancy was 7.9% (range, 4.0%–15.9%). Patients underwent jejunostomy placement between 12 and 26 weeks of gestation (median 14 weeks). Twelve to 16 Fr catheters were placed in the proximal jejunum. Maternal weight gain occured in 5 of 6 pregnancies. The mean duration of tube placement was 19 weeks (range, 8–28 weeks). All pregnancies ended with term deliveries (range, 36–40 weeks of gestation). The mean infant birth weight was 2885 g (range, 2270–4000 g). Tube-related complications were limited to dislodgement in 2 patients in the third trimester. No cases of infection, bleeding, or preterm labor occured. Conclusions: Feeding via jejunostomy is a potentially safe, effective, and well-tolerated mode of nutrition support therapy in hyperemesis gravidarum.

Parenteral Feeding Depletes Pulmonary Lymphocyte Populations

Hermsen, J. L., Gomez, F. E., Sano, Y., Kang, W., Maeshima, Y., Kudsk, K. A. — Thu, 27 Aug 2009 13:41:07 PDT

Background: The effect of parenteral nutrition (PN) on lymphocyte mass in the lung is unknown, but reduced mucosal lymphocytes are hypothesized to play a role in the reduced immunoglobulin A–mediated immunity in both gut and lung. The ability to transfer and track cells between mice may allow study of diet-induced mucosal immune function. The objectives of this study are to characterize lung T-cell populations following parenteral feeding and to study distribution patterns of transferred donor lung T cells in recipient mice. Methods: In experiment 1, cannulated male Balb/c mice are randomized to receive chow or PN for 5 days. Lung lymphocytes are obtained via collagenase digestion, and flow cytometric analysis is used to identify total T (CD3+) and B (CD45/B220+) cells. In experiment 2, isolated lung T cells from chow-fed male Balb/c mice are pooled and labeled in vitro with a fluorescent dye (carboxyfluorescein diacetate succinimidyl ester [CFSE]), and 1.1 x 10⁸ CFSE+ cells (3.1 x 10⁶ T cells) are transferred to chow-fed Balb/c recipients. Cells recovered from recipient lungs and intestinal lamina propria (LP) are analyzed by flow cytometry to determine CFSE/CD3+ T cells at 1, 2, and 7 days. In experiment 3, cells are transferred to PN-fed recipients. Results: In experiment 1, PN significantly decreases lung T- and B-cell populations compared with chow feeding. In experiment 2, CFSE+ T-cell retention is highest on day 1 in lung and LP, and decreases on day 2. Cells are gone by day 7; 98.1% of retained donor lung T cells migrate to recipient lungs and 1.9% to the intestine on day 1. Similar results are seen in experiment 3 after transfer of cells to PN-fed recipients. Conclusions: PN reduces pulmonary lymphocyte populations consistent with impaired respiratory immunity. Transferred lung T cells preferentially localize to recipient lungs rather than intestine with maximal accumulation at 24 hours. Limited cross-talk of transferred lung T cells to the intestine indicates that mucosal lymphocyte traffic might be programmed to localize to specific effector sites.

Fish Oil-Based Lipid Emulsions Prevent and Reverse Parenteral Nutrition-Associated Liver Disease: The Boston Experience

de Meijer, V. E., Gura, K. M., Le, H. D., Meisel, J. A., Puder, M. — Thu, 27 Aug 2009 13:41:07 PDT

Parenteral nutrition–associated liver disease (PNALD) is the most prevalent and most severe complication of long-term parenteral nutrition. Its underlying pathophysiology, however, largely remains to be elucidated. The currently approved parenteral lipid emulsions in the United States contain safflower or soybean oils, both rich in -6 polyunsaturated fatty acids (PUFAs). Mounting evidence indicates that the -6 PUFAs originating from plant oils in these lipid emulsions may play a role in the onset of liver injury. Fish oil–based lipid emulsions, in contrast, are primarily composed of -3 PUFAs, thus providing a promising alternative. The authors review the literature on the role of lipid emulsions in the onset of PNALD and discuss prevention and treatment strategies using a fish oil–based lipid emulsion. They conclude that a fish oil–based emulsion is hepatoprotective in a murine model of PNALD, and it appears to be safe and efficacious for the treatment of this type of liver disease in children. A prospective randomized trial that is currently under way at the authors' institution will objectively determine the place of fish oil monotherapy in the prevention of PNALD.

Micronutrient Supplementation in Adult Nutrition Therapy: Practical Considerations

Sriram, K., Lonchyna, V. A. — Thu, 27 Aug 2009 13:41:07 PDT

Preexisting micronutrient (vitamins and trace elements) deficiencies are often present in hospitalized patients. Deficiencies occur due to inadequate or inappropriate administration, increased or altered requirements, and increased losses, affecting various biochemical processes and resulting in organ dysfunction, poor wound healing, and altered immune status with deleterious sequelae. Guidelines for the 13 essential vitamins and 10 essential trace elements have been established. These recommendations, however, are applicable to healthy adults and not to critically ill patients, in whom decreased serum levels may indicate actual deficiencies or a deficiency due to redistribution. Benefits of supplementation over and above the daily requirements, which may not result in increased serum levels, are also unclear and may, in fact, be detrimental. Vitamin requirements are increased in disease states, but a similar recommendation for trace elements has not been initiated except for selenium (Se) and zinc (Zn). In practice, a multivitamin preparation and a multiple trace element admixture (containing Zn, Se, copper, chromium, and manganese) are added to parenteral nutrition formulations. Most enteral nutrition preparations also contain adequate amounts of vitamins and trace elements, although bioavailability may be an issue. Detailed information about individual micronutrient use specifically in hospitalized adult patients receiving nutrition therapy will be discussed, emphasizing the practical and clinical aspects. Clinicians are encouraged to think of micronutrients not as nutritional supplements alone but also as therapeutic agents and nutraceuticals.

Racial and Geographic Disparities in the Use of Parenteral Nutrition Among Inflammatory Bowel Disease Inpatients Diagnosed With Malnutrition in the United States

Nguyen, G. C., Munsell, M., Brant, S. R., LaVeist, T. A. — Thu, 27 Aug 2009 13:41:07 PDT

Background: Racial disparities have been described in the use of a diverse spectrum of surgical procedures. The objectives of this study are to determine whether disparities also exist for the use of parenteral nutrition (PN) in inflammatory bowel disease (IBD). Methods: The U.S. Nationwide Inpatient Sample between 1998 and 2003 is analyzed to determine PN use among IBD inpatients diagnosed with protein-calorie malnutrition and assess whether use patterns differ by race and geographical region. Results: The proportion of African American IBD admissions with protein-calorie malnutrition who receive PN is significantly lower than that in whites (19.9% vs 28.1%, P = .001), whereas there is no difference between Hispanics and non-Hispanic whites. After adjustment for gender, comorbidity, health insurance status, geographic region, and median neighborhood income, African Americans remain less likely than whites to receive PN (odds ratio [OR] 0.67; 95% confidence interval [CI], 0.50–0.89), whereas the difference between Hispanics and non-Hispanic whites is marginally significant (OR 0.65; 95% CI, 0.41–1.04). PN use varies geographically, with highest rates in the Northeast (44.3%) and lowest in the Midwest (17.3%). Uninsured patients are less than half as likely to receive PN as those with insurance (OR 0.46; 95% CI, 0.31–0.69). Compared with whites, Hispanics experience a longer time interval between admission and initiation of PN (3.5 vs 4.8 days, P = .02) and have higher rates of catheter-related complications (5.1% vs 12.2%, P = .04). Conclusions: Among IBD inpatients with clinically diagnosable malnutrition, PN use is lower among African Americans compared with whites. The underlying mechanisms of these racial variations merit further investigation.

Use of Probiotics in the Management of Chemotherapy-Induced Diarrhea: A Case Study

El-Atti, S. A., Wasicek, K., Mark, S., Hegazi, R. — Thu, 27 Aug 2009 13:41:07 PDT

Gastrointestinal disturbances (particularly diarrhea) are often induced in response to cancer treatments such as chemotherapy or radiation. Oral chemotherapeutic agents can induce diarrhea by damaging the intestinal lining. Two common oral drugs used in cancer treatment that are known to have gastrointestinal side effects are capecitabine and lapatinib. In this brief communication, the authors discuss a case study of a stage IV breast cancer patient whose chemotherapy-induced diarrhea was treated successfully with a multispecies combination of probiotics. This is a unique study in which grade 3 chemotherapy-induced diarrhea (characterized by 7–9 stools per day and associ ated with incontinence and abdominal cramping) was treated with only a multispecies combination of probiotics. Probiotics have been used to treat diarrhea in patients with irritable bowel syndrome, ulcerative colitis, pouchitis, and Crohn's disease. More recently, probiotics have been used to treat chemotherapy-induced diarrhea in colon cancer patients. This case study demonstrates that the probiotics can also be used to treat severe cases of chemotherapy-induced diarrhea in breast cancer patients. The use of different probiotics in gastrointestinal diseases is an increasingly important area of study, and more research into this area is needed. This study demonstrates that probiotics should be considered for advanced breast cancer patients with chemotherapy-induced diarrhea.

Effects of Intravenous Lipid Emulsions in Postoperative Patients

Rollins, C. J. — Thu, 27 Aug 2009 13:41:07 PDT

Use of Probiotics for Treatment of Chemotherapy-induced Diarrhea: Is It a Myth?

Miller, A. C., Elamin, E. M. — Thu, 27 Aug 2009 13:41:07 PDT

Letter to the Editor

Thornton, S. N. — Thu, 27 Aug 2009 13:41:07 PDT

"Do You Feel Misguided by All These Guidelines?"

McClave, S. A. — Thu, 11 Jun 2009 09:13:41 PDT

Defining and Classifying Cancer Cachexia: A Proposal by the SCRINIO Working Group

Bozzetti, F., Mariani, L. — Thu, 11 Jun 2009 09:13:41 PDT

Background: Although cancer cachexia is widely diffuse in the cancer patient population, there is no objective definition and classification of this syndrome. The purpose of this study is to propose a simple and quick classification that relies on the severity of the body weight loss and presence/absence of symptoms that are associated with cancer cachexia. Methods: The authors used a database of an ongoing multicenter prospective investigation on the screening of the nutrition risk of 1307 cancer outpatients from different (mainly Italian) university or scientific institutes or hospitals. The database included demographic, oncologic, clinical, and nutrition data. The patients were divided into 4 classes based on combinations of body weight loss (<10%, precachexia; ≥10%, cachexia) and the presence/absence of at least 1 symptom of anorexia, fatigue, or early satiation. The authors verified statistically whether these 4 classes were associated with the distribution of main clinical, nutrition, and oncologic variables, after adjustment for treatment status, by using the Cochrane-Mantel-Hanszel test for count data and ANOVA for continuous data. Results: Moving from "asymptomatic precachexia" (class 1) to "symptomatic cachexia" (class 4), there were statistically significant trends (P < .0001) in the percentage of gastrointestinal vs nongastrointestinal tumors, severity of cancer stage, percentage of weight loss, number of symptoms per patient, Eastern Cooperative Oncology Group (ECOG) performance status, and nutritional risk score. Conclusions: The statistical analysis has validated the classification by identifying stages with different severity of cachexia. This classification could be adopted within a comprehensive oncologic approach to the weight-losing patients, until more specific diagnostic techniques are available in clinical practice.

Rationale and Design of the Pediatric Critical Illness Stress-Induced Immune Suppression (CRISIS) Prevention Trial

Thu, 11 Jun 2009 09:13:41 PDT

Despite implementation of CDC recommendations and bundled interventions for preventing catheter-associated blood stream infection, ventilator-associated pneumonia, or urinary catheter–associated infections, nosocomial infections and sepsis remain a significant cause of morbidity and mortality in critically ill children. Recent studies suggest that acquired critical illness stress-induced immune suppression (CRISIS) plays a role in the development of nosocomial infection and sepsis. This condition can be related to inadequate zinc, selenium, and glutamine levels, as well as hypoprolactinemia, leading to stress-induced lymphopenia, a predominant T_H2 monocyte/macrophage state, and subsequent immune suppression. Prolonged immune dysfunction increases the likelihood of nosocomial infections associated with invasive devices. Although strategies to prevent common complications of critical illness are routinely employed (eg, prophylaxis for gastrointestinal bleeding, thrombophlebitis), no prophylactic strategy is used to prevent stress-induced immune suppression. This is the authors' rationale for the pediatric CRISIS prevention trial (NCT00395161), designed as a randomized, double-blind, controlled clinical investigation to determine if daily enteral supplementation with zinc, selenium, and glutamine as well as parenteral metoclopramide (a dopamine 2 receptor antagonist that reverses hypoprolactinemia) prolongs the time until onset of nosocomial infection or sepsis in critically ill children compared to enteral supplementation with whey protein. If effective, this combined nutritional and pharmacologic approach may lessen the excess morbidity and mortality as well as resource utilization associated with nosocomial infections and sepsis in this population. The authors present the design and analytic plan for the CRISIS prevention trial.

Understanding Why Patients Die After Gastrostomy Tube Insertion: A Retrospective Analysis of Mortality

Thu, 11 Jun 2009 09:13:41 PDT

Objectives: To understand the causes of mortality of inpatients receiving a percutaneous endoscopic gastrostomy (PEG) tube compared with a survival curve predicted from a model proposed by Levine et al (2007). Design: A retrospective study of patients receiving a PEG over an 18-month period. Setting: Royal United Hospital Bath, a district general hospital in the southwest of England. Patients: Fifty-five cases, with 44 found eligible for inclusion. Interventions: A Levine score was calculated for this cohort. A survival curve after PEG was produced and compared with the Kaplan-Meier curve predicted by the Levine model. Main Outcome Measures: Mortality over a period of 1 year. Results: The mortality at 1, 3, 6, and 12 months was 16%, 20%, 25%, and 28%, respectively. This matched the predicted death rate from the Levine model closely (Pearson's rank correlation coefficient = 0.96). Conclusions: The authors found that the mortality of patients receiving a PEG followed that predicted for a similar cohort of patients without PEGs in the Levine model. This suggests that the deaths observed were due to underlying comorbidities, can provide a baseline for mortality targets for PEG services, and is useful patient information regarding the risks and benefits of the procedure. The findings demonstrate that PEG does no harm and supports the accepted opinion that nutrition support is associated with a better outcome. Furthermore, they show that most deaths occur within the first month of placement and would support arguments for delaying placement until outcome from the underlying condition is more predictable.

Nutrition Intervention: A Strategy Against Systemic Inflammatory Syndrome

Oz, H. S., Chen, T. S., Neuman, M. — Thu, 11 Jun 2009 09:13:41 PDT

Background: Sepsis and septic shock syndrome are the leading causes of death in critically ill patients. Lipopolysaccharide (LPS) released by the colonic microorganisms may translocate across a compromised lumen, leading to upregulated reactive oxidative stress, inflammation, and sepsis. The authors examined an enteral formula high in cysteine (antioxidant precursor), -3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and prebiotic fructooligosaccharides (FOS) against systemic inflammatory syndrome. Methods: Rats were allocated to (1) standard soy-based diet high in cysteine and crude fiber and devoid of EPA-DHA (CHOW); (2) whey-peptide-based liquid diet high in cysteine, EPA-DHA, and FOS (CYSPUFA); or (3) casein-based liquid isonitrogenous diet, low in cysteine and devoid of EPA-DHA-FOS (CASN). Liquid diets provided 25% and CHOW, 23% of calories as protein. After 6 days on diets, rats received an intraperitoneal injection of LPS or saline. Animals gained weight on their respective diets and lost weight after LPS administration. The CYSPUFA group lost considerably less weight (vs CASN or CHOW, P < .05). Inflammatory cytokines significantly increased by 4 hours and subsided 18 hours after assault. The CASN group showed elevated liver enzyme alanine aminotransferase release from damaged hepatocytes and developed severe hepatic pathology with low hematocrit. The CHOW group developed more severe hepatic lesions compared with those on liquid diets. Concentration of liver enzyme and pathology were improved in rats receiving CYSPUFA. Conclusions: Data indicate that CYSPUFA, a diet rich in EPA-DHA-FOS, protects against LPS-induced systemic inflammatory responses and warrants clinical studies in critically ill patients.

Effect of Dietary Fatty Acid Composition on Th1/Th2 Polarization in Lymphocytes

Thu, 11 Jun 2009 09:13:41 PDT

Background: It has become increasingly clear that polyunsaturated fatty acids (PUFAs) have immunomodulatory effects. However, the intake of these fatty acids used in animal studies often greatly exceeds dietary human intake. Whether differences in the composition of fatty acids that are consumed in amounts consistent with normal dietary intake can influence immune function remains uncertain. Methods: We manufactured 3 types of liquid diet, related to modified fatty acid composition (-6/-3 = 0.25, 2.27 and 42.9), but excluding eicosapentaenoic acid and docosahexaenoic acid, based upon a liquid diet used clinically in humans. We assessed CD3-stimulated cytokine production of splenocytes in female BALB/c mice (n = 4 per group) fed 1 of 3 liquid diets for 4 weeks. We also measured the cytokine production of peripheral blood mononuclear cells stimulated with phorbol myristate acetate and ionomycin in humans at the end of a 4-week period of consumption of 2 different liquid diets (-6/-3 = 3 and 44). Results: We found that the ratio of interfero - (IFN-) / interleukin-4 (IL-4) was significantly higher in mice fed the -3 rich diet than in others. In humans, IFN- / IL-4 was significantly higher after the -3 versus the -6 enhanced diet. Conclusions: Differences in the composition of -3 and -6 PUFAs induces a shift in the Th1/Th2 balance in both mouse and human lymphocytes, even when ingested in normal dietary amounts. An -3 rich diet containing -linolenic acid modulates immune function.

Biofilms, Infection, and Parenteral Nutrition Therapy

Machado, J. D. C., Suen, V. M. M., de Castro Figueiredo, J. F., Marchini, J. S. — Thu, 11 Jun 2009 09:13:41 PDT

Parenteral nutrition therapy is used in patients with a contraindication to the use of the gastrointestinal tract, and infection is one of its frequent and severe complications. The objective of the present study was to detect the presence of biofilms and microorganisms adhering to the central venous catheters used for parenteral nutrition therapy by scanning electron microscopy. Thirty-nine central venous catheters belonging to patients with clinical signs of infection (G1) and asymptomatic patients (G2) and patients receiving central venous catheters for clinical monitoring (G3) were analyzed by semiquantitative culture and scanning electron microscopy. The central venous catheters of G1 presented more positive cultures than those of G2 and G3 (81% vs 50% and 0%, respectively). However, biofilms were observed in all catheters used and 55% of them showed structures that suggested central venous catheters colonization by microorganisms. Approximately 53% of the catheter infections evolved with systemic infection confirmed by blood culture. The authors conclude that the presence of a biofilm is frequent and is an indicator of predisposition to infection, which may even occur in patients who are still asymptomatic.

The Role of Pretreatment Percutaneous Endoscopic Gastrostomy in Facilitating Therapy of Head and Neck Cancer and Optimizing the Body Mass Index of the Obese Patient

Thu, 11 Jun 2009 09:13:41 PDT

Background: Chemoradiation of head and neck cancer induces severe dysphagia and malnutrition, which may lead to interruptions in therapy and reduction in its efficacy. Percutaneous endoscopic gastrostomy (PEG) feedings bypass the oropharynx, allowing administration of nutrients and medications into the stomach, thus preventing malnutrition, dehydration, and treatment interruption. Methods: Medical records of 161 patients treated for head and neck cancer who had PEGs placed prior to chemoradiation and 2 PEGs placed during chemoradiation were reviewed from the date of PEG placement throughout treatment and utilization. The objective was to determine the contribution of pretreatment PEGs to the therapy of patients with head and neck cancer and to optimize their body mass index. Results: Severe chemoradiation-induced dysphagia developed in 160 patients (98%), necessitating PEG utilization for feeding and hydration. PEGs were used for a mean 251 ± 317 days. Significant complications related to PEG placement and utilization were infrequent. PEG feeding allowed chemoradiation to continue without interruption in 93% of patients. Individualized feeding regimens optimized body mass index in obese and overweight patients with a decline from 33.0 ± 3.4 to 28.4 ± 4.8 kg/m² (P < .001) and 27.3 ± 1.5 to 24.6 ± 2.7 kg/m² (P < .001), respectively. Radiation-induced strictures developed in 12% of patients, requiring endoscopic dilatation. Conclusions: Enteral feeding through prechemoradiation-placed PEGs is an effective and safe method for nutrition and hydration of patients with head and neck cancer undergoing chemoradiation. PEGs allowed chemoradiation to proceed with minimal interruptions despite severe dysphagia, which excluded oral intake for prolonged periods.

Starvation-Induced Proximal Gut Mucosal Atrophy Diminished With Aging

Thu, 11 Jun 2009 09:13:41 PDT

Background: Starvation induces small bowel atrophy with increased intestinal epithelial apoptosis and decreased proliferation. The authors examined these parameters after starvation in aged animals. Methods: Sixty-four 6-week-old and 26-month-old C57BL/6 mice were randomly assigned to either an ad libitum fed or fasted group. The small bowel was harvested at 12, 48, and 72 hours following starvation. Proximal gut mucosal height was measured and epithelial cells counted. Apoptosis was identified by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining. Proliferation was determined by immunohistochemical staining for proliferating cell nuclear antigen. Comparison of fed vs fasted and adult vs old groups was done by one-way ANOVA with Tukey's test and unpaired Student's t test. Significance was accepted at P < .05. Results: Aged mice had higher proximal gut weights, mucosal heights, and cell numbers at baseline compared with the adult group (P < .05). The rate of apoptosis was lower in the aged (P < .05), but proliferation was not different between groups before starvation. After starvation, proximal gut wet weight decreased only in adult mice (P < .05). Gut mucosal height and mucosal cell number decreased more in adult than in aged mice (P < .05). This was related to decreased proliferation only in the adult group (P < .05). The fold of epithelial apoptosis that increased was higher in the aged group than in the adult group after starvation (P < .05). Conclusions: Gut mucosal kinetics change with age and have lower rates of apoptosis and greater mucosal mass; the character of starvation-induced atrophy is diminished with aging.

Need for Thiamine in Peripheral Parenteral Nutrition After Abdominal Surgery in Children

Thu, 11 Jun 2009 09:13:41 PDT

Background: Thiamine blood concentrations of pediatric patients receiving peripheral parenteral nutrition change during the postoperative period. In addition, the need to administer thiamine after surgery has not yet been fully studied in children receiving peripheral parenteral nutrition. Objective: The objective of this prospective study is to clarify whether pediatric patients require the administration of thiamine while receiving peripheral parenteral nutrition after abdominal surgery. Patients: Fifteen children were divided into 2 groups; 1 group received peripheral parenteral nutrition without thiamine after surgery (n = 7), whereas the other group received peripheral parenteral nutrition with thiamine after surgery (n = 8). In both groups, thiamine blood concentrations were measured on the preoperative day, and changes in thiamine concentration over time were measured during the starvation period from the first to the fifth postoperative day. Results: Preoperative thiamine blood concentrations were within the normal range in both groups. In the group receiving peripheral parenteral nutrition without thiamine, the thiamine concentration gradually decreased with time after the operation, whereas the concentration remained within the normal range in the group receiving peripheral parenteral nutrition with thiamine. Among the 7 patients receiving peripheral parenteral nutrition without thiamine, the thiamine concentration in 3 patients was below the normal range on the fifth postoperative day. Conclusion: During the starvation period after abdominal surgery, thiamine blood concentrations decreased in pediatric patients receiving peripheral parenteral nutrition without thiamine. Therefore, clinicians treating pediatric patients should add thiamine to the peripheral parenteral nutrition solution during the short starvation period after abdominal surgery.

Effect of Sesame Oil on Acidified Ethanol-Induced Gastric Mucosal Injury in Rats

Hsu, D.-Z., Chu, P.-Y., Liu, M.-Y. — Thu, 11 Jun 2009 09:13:41 PDT

Background: Exposure of gastric mucosa to concentrated ethanol induces acute gastritis. Gastric mucosal lipid peroxidation plays a significant role in the pathogenesis of ethanol-induced gastric mucosal lesions. The aim of this study was to investigate the effect of sesame oil on acidified ethanol-induced gastric mucosal damage in rats. Methods: We performed gastric bilateral vagotomy in rats. A small incision on forestomach was made and stomach content was expelled. Normal artificial gastric acid (54 mM NaCl plus 100 mM HCl) or acidified ethanol (30% ethanol plus 150 mM HCl) was instilled into the stomach. Gastric lipid peroxidation, glutathione, and nitric oxide levels were measured 3 hours after acidified ethanol administration. Results: Acidified ethanol caused mucosal ulceration, luminal hemorrhage, lipid peroxidation, and a lower level of mucosal glutathione and nitric oxide production. Pretreatment of sesame oil, but not mineral oil, significantly decreased acidified ethanol-induced mucosal ulcer formation and luminal hemorrhage. Sesame oil reduced mucosal lipid peroxidation, as well as glutathione and nitric oxide production in acidified ethanol-treated stomachs. Furthermore, both sesame oil and mineral oil did not affect serum ethanol concentration in acidified ethanol-treated rats. Conclusion: Sesame oil attenuates acidified ethanol-induced gastric mucosal injury by reducing oxidative stress in rats.

Ghrelin Does Not Predict Adaptive Hyperphagia in Patients With Short Bowel Syndrome

Compher, C. W., Kinosian, B. P., Metz, D. C. — Thu, 11 Jun 2009 09:13:41 PDT

Background: Adaptive hyperphagia is associated with reduced dependence on parenteral nutrition in patients with short bowel syndrome, but mechanisms have not been described. Ghrelin (GHR) has orexigenic effects, whereas peptide YY (PYY) reduces intake. GHR also acts as a hormone to control body fat stores. The authors evaluated whether GHR or PYY was related to caloric intake or absorption in patients with short bowel syndrome and whether GHR was associated with body mass index. Methods: Patients were admitted twice for nutrient balance. Height and body weight were obtained using standardized protocols. Energy intake >40 kcal/kg/day was defined as adaptive hyperphagia. Fasting plasma PYY and GHR were assayed in duplicate with Linco enzyme-linked immunosorbent assay kits. Results: The median age of the 7 study participants was 62 (range, 45-66) years, time with short bowel syndrome was 6.6 (range, 2-29) years, and body mass index was 21.2 kg/m² (range, 19-27.7). Five patients had adaptive hyperphagia. Neither GHR nor PYY was significantly related to energy intake or absorption (GHR: R = 0.22 and R = –0.233, PYY: R = 0.10 and R = –0.13). Body mass index trended toward an inverse association with GHR (GHR: R = –0.540, P = .211). Conclusion: The rigorous adaptive hyperphagia seen in these patients with short bowel syndrome was not related to fasting GHR or PYY, suggesting the need to explore other mechanisms.

Dexamethasone and GLP-2 Given to Lactating Rat Dams Influence Glucose Uptake in Suckling and Postweanling Offspring

Thu, 11 Jun 2009 09:13:41 PDT

Background: Glucagon-like peptide–2 (GLP-2) enhances intestinal absorption in adult animals. Glucocorticosteroids accelerate the ontogeny of the intestine and increase sugar uptake in adult animals. Modifying the maternal diet during lactation alters nutrient uptake in the offspring. The authors hypothesized that GLP-2 and dexamethasone, when administrated to lactating rat dams, enhance sugar uptake in the suckling and postweanling offspring. Methods: Rat dams were treated during lactation with GLP-2 (0.1 µg/g/day subcutaneously [SC], twice daily), dexamethasone (0.128 µg/g/day SC, once daily), GLP-2 + dexamethasone (same doses), or placebo. The suckling offspring were sacrificed at 19–21 days of age, and the postweanlings were sacrificed 4 weeks later. Intestinal glucose and fructose uptake was assessed using an in vitro ring technique. Results: GLP-2 and dexamethasone resulted in lower body weights, and dexamethasone caused intestinal atrophy in sucklings. The jejunal atrophy in sucklings given dexamethasone was prevented by GLP-2 + dexamethasone. In sucklings, the maximal transport rate and the Michaelis affinity constant for ileal glucose uptake were both increased by GLP-2 and GLP-2 + dexamethasone. In contrast, in postweanlings, the maximal transport rate for jejunal glucose uptake was reduced by dexamethasone and GLP-2, as was ileal fructose uptake. Conclusions: Treating lactating rat dams with GLP-2 or dexamethasone enhances glucose uptake in sucklings, but the late effect is a reduction in glucose and fructose absorption in postweanlings. The nutritional significance of these findings remains to be established.

Use of Nutrition to Prevent Stress-induced Immunosuppression in the Pediatric Intensive Care Unit: A Clinical Trials Minefield

Neu, J. — Thu, 11 Jun 2009 09:13:41 PDT

Do Obese Patients Have Specific Nutrition Goals in Cases of Cancer?

Genton, L., Pichard, C. — Thu, 11 Jun 2009 09:13:41 PDT

Comment On: Probiotic Prophylaxis in Predicted Severe Acute Pancreatitis: A Randomized, Double-Blind, Placebo-Controlled Trial

McClave, S. A., Heyland, D. K., Wischmeyer, P. E. — Thu, 11 Jun 2009 09:13:41 PDT

BACKGROUND: Infectious complications and associated mortality are a major concern in acute pancreatitis. Enteral administration of probiotics could prevent infectious complications, but convincing evidence is scarce. Our aim was to assess the effects of probiotic prophylaxis in patients with predicted severe acute pancreatitis. METHODS: In this multicentre randomised, double-blind, placebo-controlled trial, 298 patients with predicted severe acute pancreatitis (Acute Physiology and Chronic health Evaluation [APACHE II] score > or =8, Imrie score > or =3, or C-reactive protein >150 mg/L) were randomly assigned within 72 h of onset of symptoms to receive a multispecies probiotic preparation (n = 153) or placebo (n = 145), administered enterally twice daily for 28 days. The primary endpoint was the composite of infectious complications—ie, infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis, or infected ascites—during admission and 90-day follow-up. Analyses were by intention to treat. This study is registered, number ISRCTN38327949. FINDINGS: One person in each group was excluded from analyses because of incorrect diagnoses of pancreatitis; thus, 152 individuals in the probiotics group and 144 in the placebo group were analysed. Groups were much the same at baseline in terms of patients' characteristics and disease severity. Infectious complications occurred in 46 (30%) patients in the probiotics group and 41 (28%) of those in the placebo group (relative risk 1.06, 95% CI 0.75-1.51). 24 (16%) patients in the probiotics group died, compared with nine (6%) in the placebo group (relative risk 2.53, 95% CI 1.22-5.25). Nine patients in the probiotics group developed bowel ischaemia (eight with fatal outcome), compared with none in the placebo group (p = 0.004). INTERPRETATION: In patients with predicted severe acute pancreatitis, probiotic prophylaxis with this combination of probiotic strains did not reduce the risk of infectious complications and was associated with an increased risk of mortality. Probiotic prophylaxis should therefore not be administered in this category of patients. (Lancet. 2008;371:651-659)

Besselink MG, van Santvoort HC, Buskens E, et al; Dutch Acute Pancreatitis Study Group

Letter to the Editor

Hemila, H. — Thu, 11 Jun 2009 09:13:41 PDT

Author Response

Cotton, B. A., Dossett, L. A., Collier, B. R. — Thu, 11 Jun 2009 09:13:41 PDT

Letter to the Editor

Wanten, G. J. — Thu, 11 Jun 2009 09:13:41 PDT

Letter to the Editor

Driscoll, D. F. — Thu, 11 Jun 2009 09:13:41 PDT

Letter to the Editor

Correia, M. I. T. D. — Thu, 11 Jun 2009 09:13:41 PDT

Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients, 2009

Mon, 27 Apr 2009 11:13:19 PDT

A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child

Mehta, N. M., Compher, C., A.S.P.E.N. Board of Directors — Mon, 27 Apr 2009 11:13:19 PDT

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient:: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

Mon, 27 Apr 2009 11:13:19 PDT

An Evaluation of the Neuroendocrine Response to Sleep in Pediatric Burn Patients

Gottschlich, M. M., Khoury, J., Warden, G. D., Kagan, R. J. — Mon, 27 Apr 2009 11:13:19 PDT

Introduction: Previous work demonstrated reduced stage 3+4 and rapid eye movement (REM) sleep following burn injury. This study evaluated the hormonal effects of drug intervention on measures of endocrine status. A secondary objective examined the relationship between hormones and sleep stage distribution. Methods: Forty patients 3–18 years of age with a mean percent total body surface area burn of 50.1 ± 2.9 were randomly assigned to zolpidem or haloperidol utilizing a blinded crossover design. Polysomnography was performed 6 nights, 3/week over 2 weeks. Each week's first night of monitoring was conducted without medication, serving as a baseline. Hormonal levels (epinephrine, norepinephrine, growth hormone, melatonin, dehydroepiandrosterone [DHEA], serotonin, cortisol) were obtained at 0600 h each study day. Results: Both drugs were associated with increased DHEA levels (P < .03); no other hormones were affected by medication. Significant inverse correlation was observed between REM sleep and epinephrine (r = –.34, P = .004) and norepinephrine levels (r = –.45, P = .02). A positive relationship existed between serotonin and sleep stage 3+4 (r = 0.24, P = .01) and REM (r = 0.48, P = .01). No other significant associations were identified between hormones and sleep. Conclusions: This work characterizes the relationship between sleep deprivation and select endocrine parameters postburn. Drug interventions utilized in this study were either ineffective or insufficient in modulating improved hormonal response. Significance of zolpidem's and haloperidol's effect on serum levels of DHEA is unclear. The inverse correlation of epinephrine with REM may suggest that hypermetabolism associated with burns is partly due to lack of REM sleep. Questions remain regarding the effects of sleep deprivation on metabolism and clinical outcome.

Hepatic Indicators of Oxidative Stress and Tissue Damage Accompanied by Systemic Inflammation in Rats Following a 24-Hour Infusion of an Unstable Lipid Emulsion Admixture

Driscoll, D. F., Ling, P.-R., Andersson, C., Bistrian, B. R. — Mon, 27 Apr 2009 11:13:19 PDT

Background: Use of lipid emulsions in parenteral nutrition therapy is an important source of daily energy in substitution of potentially harmful glucose calories when given in excess in the intensive care unit. When added to parenteral nutrition (PN) admixtures as a total nutrient admixture (TNA), the stability and safety of the emulsion may be compromised. Development of a rat model of a stable vs unstable lipid infusion would enable a study of the potential risk. Design: Prospective, randomized, controlled study. Methods: Surgical placement of a jugular venous catheter for the administration of TNAs was performed. Two groups were studied: a stable or s-TNA (n = 16) and an unstable or u-TNA (n = 17) as a 24-hour continuous infusion. Stability of TNAs was determined immediately before and after infusion using a laser-based method approved by the United States Pharmacopeia. Results: Blood levels of aspartate aminotransferase, glutathione-S-transferase, and C-reactive protein were significantly elevated in u-TNA vs s-TNA (P < .05). Also, liver tissue concentrations of malondialdehyde were significantly higher in the u-TNA group (P < .05), and triglyceride tissue levels were also higher in u-TNA and approached statistical significance (P = .077). Conclusions: Unstable lipid infusions over 24 hours produce evidence of hepatic accumulation of fat associated with oxidative stress, liver injury, and a low-level systemic inflammatory response.

Cumulative Energy Imbalance in the Pediatric Intensive Care Unit: Role of Targeted Indirect Calorimetry

Mehta, N. M., Bechard, L. J., Leavitt, K., Duggan, C. — Mon, 27 Apr 2009 11:13:19 PDT

Introduction: Failure to accurately estimate energy requirements may result in underfeeding or overfeeding. In this study, a dedicated multidisciplinary nutrition team measured energy expenditure in critically ill children. Methods: Steady-state indirect calorimetry was used to obtain measured resting energy expenditure, which was compared with equation-estimated energy expenditure and the total energy intake for each subject. The children's metabolic status was examined in relation to standard clinical characteristics. Results: Sixteen measurements were performed in 14 patients admitted to the multidisciplinary pediatric intensive care unit over a period of 12 months. Mean age of subjects in this cohort was 11.2 years (range 1.6 months to 32 years) and included 7 males and 7 postoperative patients. Altered metabolism was detected in 13 of 14 subjects and in 15 of 16 (94%) measurements. There was no correlation between the metabolic status of subjects and their clinical characteristics. Average daily energy balance was 200 kcal/d (range –518 to +859 kcal/d). Agreement between measured resting energy expenditure and equation-estimated energy expenditure was poor, with mean bias of 72.3 ± 446 kcal/d (limits of agreement –801.9 to + 946.5 kcal/d). Conclusions: A disparity was observed between equation-estimated energy expenditure, measured resting energy expenditure, and total energy intake, with a high incidence of underfeeding or overfeeding. A wide range of metabolic alterations were recorded, which could not be accurately predicted using standard clinical characteristics. Targeted indirect calorimetry on high-risk patients selected by a dedicated nutrition team may prevent cumulative excesses and deficits in energy balance.